Understanding Self-injury from Personal Experience

Self-harm has increased in frequency in the past years; however, it is still being treated as if it were a new occurrence. There is still very scarce research done on it because of the controversy behind the condition. Self-harm is not as simple as cutting. It is as complex as the individual who relies on it. There different categories and different degrees based on how the person uses self-harm and to what degree. There has been recent debate on whether or not this should be its own disorder or just a symptom of other mental disorders such as borderline personality disorder. The general public finds it hard to wrap their minds around the idea of self-harm. It is difficult to imagine that pain could be self-inflicted to relieve stress. The truth of the matter is, though, that these individuals need help. They require someone that they can confide in who can help them sort through these emotions and find new ways to cope instead of injuring themselves.

Pain. What is pain? The International Association for the Study of Pain’s widely used definition states that pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage. Pain motivates a person to get away from damaging situations, to protect a damaged body part while it heals, and/or to avoid similar experiences in the future. However, some do the opposite of avoid it. They crave it. It is their pathway to relief of the stress that society throws at them. They inflict it on themselves as punishment, or they do it to feel something other than the numbness that consumes them, to know that they are alive. It is an insatiable urge that grows with each passing day. The more you do it the more you need it and the stronger the pain has to be. It starts with one moment. One moment of weakness. You’ve hit rock bottom and all you want to do is scream and cry away the pain and hurt hidden in the depths of your mind. To end the suffering that destroys you from the inside out.

Self-harm is shoved under the rug like a dirty mess that you don’t want your guests to see. It gets hidden under jeans and long sleeves and 10 or more bracelets in the dead of summer. Those who suffer through the pain that not only they inflict on themselves but the pain that society throws on them as well are forced to keep their suffering a secret for fear of rejection and the judging eyes of their peers. No one finds pleasure in being called an “attention whore” or being called “insane”. The fear of being caught in this taboo ritual is extreme. “Normal” people would cringe at the thought of taking a blade to their forearm and pressing down to slice into their own flesh and to find temporary peace in this habit is unfathomable. But there are those who find solace in these late night ceremonies where they take the sharpest object in their possession and watch their blood flow freely from their skin.

This condition has received increasing attention during recent years. There has also been an increase in awareness by the general public since 1997 when Princess Diana admitted on national television that she deliberately harmed herself to cope with her disastrous marriage. Johnny Depp has also revealed to the public that he bears scars from wounds that he inflicted on himself. The plot of “Female Perversions,” a recent movie that was based on the book of the same name by Louise Kaplan, hinges on the discovery of a young girl cutting herself. And Steven Levenkron recently published “The Luckiest Girl in the World,” about a teenage self-injurer. However, even with all the recent media publications, there is still much to be done in the way of increasing awareness and understanding about the problem of self-injury. (Egan 1997, V.J. Turner 2002)

The most important issue is dealing with the myths and stereotypes surrounding this disorder and to begin to find practical treatments such as those that have been applied to anorexia nervosa and bulimia. It is important that professionals and parents alike, and the general public, cease to cringe in fear, panic, or freeze in shock when being notified about or witnessing a person who cuts or burns themselves repeatedly. For years there has been a debate among mental health specialists over whether self-harm is an illness by itself, or whether this behavior is one of the symptoms of health problems, like depression, anxiety, or borderline personality disorder. Researchers who specialize in this field say fear of lawsuits from studying such dangerous behavior if a subject harms him or herself, and a lack of a general agreement about whether self-injury is a distinct illness or simply a behavior linked to suicide, have prevented the progress of understanding the phenomenon. (Lazar 2013, V.J. Turner 2002)

There is still much work left to be done with advancing the understanding of self-harm as well as the development of new treatment strategies that work and in conducting more studies like it has been done for alcohol, drug abuse, anorexia nervosa, and bulimia. Determining what works best for what type of person and the development of newer methods are still subjects that require much research. It is suggested that along with discouraging the self-injurious behavior, there must also be an intervention in the conditions that keep it going. These interventions include: exploration of other methods for reducing the distress, teaching mental and behavioral strategies for dealing with stress-inducing situations and painful internal thoughts, strengthening the ability to control internal emotional ups and downs so that external methods (such as self-harm) feel less necessary, and reducing the stress and symptoms that may motivate the self-injurious behaviors. The unquestionable truth is that acts of self-harm are unsettling to the general public, and even to mental health professionals. The impulsive nature of these patients is frustrating to deal with at times, but no more than the impulsivity of alcoholics when they reach for another drink. (V.J. Turner 2002)

What is self-injury? It has been defined as intentional damage to the body or a body part, not with the intent of committing suicide, but to manage painful emotions that words cannot express. It can include cutting or burning the skin, or bruising oneself through a planned accident. It can also mean scratching the skin until it bleeds, or interfering with the healing process of a wound. In extreme cases, a self-injurer can break his or her own bones, amputate their own digits, eat harmful substances, or inject toxins into their bodies. While self-injury may bring a temporary sense of calm and a release of tension, it’s usually followed by guilt and shame and the return of painful emotions. And with self-injury comes the possibility of more serious and even lethal self-aggressive actions. This disorder usually begins in adolescence and continues over many years. Just as in other addictive disorders, there are repetitive incidents that increase in recurrence and seriousness as time goes on. In other words, as time goes on you build tolerance, just like in alcoholism or in substance abuse, and more is needed in order to reach that “high”. (Conterio 1998, Mayo Clinic 2012, V.J. Turner 2002)

The question still stands as to what goes on in the mind of a person that self-injures? In 1983 two authors wrote about the emotional and psychological side of self-harm. They describe the emotional/psychological symptoms frequently seen in people who self-harm as the following: sudden and recurring impulses to harm oneself without the ability to resist, a sense of being “trapped” in an unbearable situation that cannot be coped with or controlled, an increasing sense of agitation, anxiety, and anger, a restricted ability to think of more reasonable options for action, a sense of mental relief after self-injury, and a depressive mood although no suicidal intention is present. However, there are aspects of this disorder that are found among “normal” people and among people with milder disorders. Self-injury includes a range of behaviors, some of which are not so different distressing habits of the healthy population. How many people do you know, yourself included, who pick at acne, bite their nails, or scratch mosquito bites until they bleed? How many people go on starvation diets to fit into a certain pair of jeans? Where is the line drawn between the harmless things that people do to their own bodies and those that require serious attention? (V.J. Turner 2002, Conterio 1998)

Self-Injury has been classified into three major types: major self-mutilation, stereotypic self-mutilation, and superficial (or moderate) self-mutilation. Major self-mutilation is the most extreme and also the least common. This type of self-harm is categorized by the fact that although the acts are infrequent they involve a large amount of tissue being removed or destroyed. This can include self-castration, amputation, or eye-gouging. Major self-mutilation is most commonly associated with psychosis or acute drug intoxication. Stereotypic self-mutilation consists of fixed and repetitive patterns. The most common form is head banging, where a person hits their head repeatedly with a hard object to overwhelm the emotional pain. This type of self-harm is found predominantly in the mentally retarded in institutions but it has also been found in those with autism or schizophrenia. (Holmes 2000)

Superficial self-mutilation is not lethal and involves relatively little tissue damage. This type of self-harm can develop addictive qualities and can become a constant fixation for its sufferers. The most common method of self-harm under this category is cutting, which involves making cuts or severe scratches on different parts of your body with a sharp object. Other forms of self-harm include: burning (with lit matches, cigarettes or hot sharp objects like knives), carving words or symbols on the skin, breaking bones, hitting or punching, piercing the skin with sharp objects, head banging, biting, pulling out hair, and persistently picking at or interfering with wound healing. This category of self-harm can be further divided into three subcategories: compulsive, episodic, and repetitive. (Holmes 2000, Mayo Clinic 2012)

Compulsive self-harm is seen in hair pulling, skin picking and skin rubbing that is done to remove perceived faults or blemishes in the skin. These acts are common in OCD patients. The person tries to relieve stress and prevent a bad thing from happening by engaging in self-harm. OCD is marked by persistent unwanted thoughts (the obsession) along with behavior that is repetitive (the compulsion) which is supposed to ease the uneasy feelings. (Holmes 2000)

The difference between episodic and repetitive self-harm is that episodic self-harm is engaged in from time to time by people who don’t otherwise think about it and do not think of themselves as self-injurers. It is commonly a symptom of some other psychological disorder. However, that which begins as occasional or episodic self-harm can become repetitive self-harm. Repetitive self-harm is characterized by thinking about self-injury even when one is not engaged in it and the person recognizes him or herself as a self-injurer. Episodic self-harm becomes repetitive when that which was only a symptom of disease progresses to become a disease in and of itself. (Holmes 2000)

Most self-harmers develop a set routine of self-injury that they plan for and engage in daily. Others are more random and act only when difficult feelings come upon them. Some hide razor blades in lockers, nightstands, or other places so that they are prepared for whenever the urge may appear. They also hold a multitude of views about their own behavior. Many can admit that their actions are harmful but feel incapable of stopping because of solace it provides them. They believe they are sending the message that they are tough and that they can take on anything. They find pride in their scars. Their warped form of thinking is complex and has multiple sides. A patient could have a nearly amputated limb and say “I’m not as bad as the rest”, while others say they are ashamed of the vandalism they have left on their bodies and would do anything to erase it. (Conterio 1998)

It has been estimated that about 2 million people self-injure in the US. This daunting number includes people from all different walks of life, from actors like Johnny Depp, to the typical teenager in your community. Females are at greater risk of self-injuring than males are. Most people who self-injure are teenagers and young adults. Some people who injure themselves were neglected, or sexually, physically or emotionally abused, or experienced other traumatic events. In addition, self-injury is commonly associated with certain mental disorders, such as borderline personality disorder, depression, anxiety disorders, post-traumatic stress disorder and eating disorders. People who harm themselves often do so while under the influence of alcohol or illegal drugs. However, there are many other characteristics that have been seen in self-injurers. These people may have strong feelings of self-hatred and can feel that they are not good enough when compared to others. They can be highly sensitive to rejection and can seem constantly angry (usually with themselves) or have aggressive feelings. They tend to suppress these feelings or direct them inward. They also tend to be impulsive and act directly on what their mood may be at the moment. Also, they tend to not plan for the future, are suicidal or depressed, self-destructive, suffer from chronic anxiety, and can be irritable. In addition, they do not feel as if they have much control over their lives and do not believe they are skilled at coping, and in fact they usually do not have an array of coping mechanisms. (Holmes 2000, Mayo Clinic 2012)

Self-injurers can also have a low capacity to form and sustain stable relationships. They complain of having poor social skills and an inability to react to the needs and concerns of others. A self-injurer can also fear change. This change can manifest itself in any kind of new experience, be it people, places, or events. They may have an inability or unwillingness to take adequate care of themselves, such as eating a nutritional diet, getting sufficient exercise and sleep, and good hygiene. They can tend to have low self-esteem along with a powerful need for love and acceptance from others. They will go to extremes to receive demonstrations of love and caring from others, including taking on too much blame for what happens in a relationship or adopting a caretaking role when it is unhealthy or even dangerous for them to do so. (Conterio 1998)

How many times have you or someone you know gotten so angry or frustrated that banged your fist on the table to express how you felt? Have you ever punched a pillow or wall or smashed something? Or even just bit your lip to hold back tears? Whether or not you engage in self-injury, you could probably relate to the occasional need to blow off emotional steam through physical means. The activity releases endorphins which in turn soothes the nervous system. A patient of self-injury will often have a heightened or extreme experience of this sensation. They believe it is easier to deal with physical pain than emotional pain. Their definition of pain highly varies from that of other people. (Conterio 1998)

What compels these people to cause such harm to themselves? One might assume that people who cut do so because of an inability to express emotion. Although this may be a feasible reason, the following explanations shed additional light on why some may self-harm. Self-punishment is a common reason among self-injurers, an inability to express emotions that may perhaps seem too painful or confusing to put into words, regaining self-control, feeling lost and abandoned, a way to say, ‘Look, I am in control now”. It can also be due to feelings of revenge, anger or resentment toward someone. The cutter doesn’t want, or lacks the ability, to confront the person, so the cutter’s body becomes the only way of communicating with the other person. Self-harm can also be used to show mortality or regain a sense of living. The pain from the self-injury or the sight of blood serves as tangible proof to the cutter that they are, in fact, alive. It can also serve to relieve tension or release anger just like another physical coping mechanism, crying. Both normally result from negative feelings of hurt or anger, both involve the shedding of bodily fluid, both are often described as uncontrollable, and both leave the person feeling tired, relieved and calm afterward. (Spiratos 2003)

Presently, self-harm is not classified as a psychological disorder by the American Psychiatric Association. Instead, the APA’s complete reference work on psychological problems, the Diagnostic and Statistical Manual of Mental Disorders, includes self-mutilative acts as part of another psychological problem called borderline personality disorder. This disorder is characterized by a pattern of unstable relationships, impulsive behavior, and immediate or drastic shifts in self-image. The nine criteria for this disorder are: frantic efforts to avoid real or imagined abandonment, a pattern of unstable relationships, unstable self-image, impulsivity regarding two areas that could be considered dangerous (substance abuse, reckless driving, binge eating, etc.), ongoing suicidal behavior or self-mutilating behavior, instability due to mood swings, chronic feelings of emptiness, intense anger or difficulty controlling feelings of anger, and brief occurrences of paranoid feelings. However, there is some evidence that BPD is frequently misdiagnosed. In 1992 a study was conducted on 89 patients diagnosed with BPD and it was found that only 36 had actually met the minimum of 5 criteria necessary to be correctly diagnosed with this disorder. This indicates that the disorder may be over diagnosed and that possibly some doctors misclassify their “problem” patients as borderline personality patients. (Holmes 2000)

Other mental health specialists believe that obsessive compulsive disorder may also cause, or lead to, self-injurious behaviors. OCD is characterized by persistent obsessions or compulsions that are severe and cause the person distress. A person with obsessions will attempt to ignore or suppress the thought, or try to neutralize it with another action or thought. This is the compulsion. Compulsions include behaviors or mental acts that are intended to reduce the anxiety or stress. Among those who have been diagnosed with OCD, the self-injurious behavior usually manifests itself as trichotillomania (compulsive pulling of head or body hair) or compulsive picking or scratching at skin. (Holmes 2000, Conterio 1998, V.J. Turner 2002)

Among the problems commonly associated with self-harm are the symptoms of post-traumatic stress disorder. This disorder is most common in children who have been physically or sexually abused or neglected. A sufferer of this condition may experience the following: intrusive and distressing memories and dreams of a traumatic event, a desire to avoid all things that could be reminders of said traumatic event, a reduced interest in activities that were previously enjoyed, distancing from other people, inability to feel emotion involving intimacy and tenderness, and persistent feelings of anxiety, anger, and irritability. (Holmes 2000, Conterio 1998)

It is common for people who engage in self-harm to also suffer from and eating disorder such as anorexia nervosa or bulimia. Anorexia nervosa is an eating disorder that is categorized by a fear of putting on weight. People with this disease may feel overweight even if their actual body weight is 15% below what it should be for their height and age. Anorexia is similar to self-harm in many aspects. Generally this disorder is found in women who are young adults. The main causes of anorexia, as with self-injury, include stress and childhood trauma or sexual abuse. Anorexics attempt to regain control of their lives by controlling what they eat and how much they weigh, just as someone who cuts attempts to control their emotional suffering through physical pain. (Holmes 2000)

Bulimia is much more common than anorexia and it is found in women who are usually older than those who are anorexic. It is also very common for a person to suffer from both disorders in conjunction. It is estimated that about 50% of anorexics also suffer from bulimia. People with bulimia nervosa engage in regular periods of binging (eating a large amount of food at once) and then proceed to force themselves to vomit what they have just consumed, this is called purging. This purging, which is usually done at least once a day, can be uncomfortable or even painful, but for bulimics it offers the same relief from emotional stress that a person who self-harms gains from cutting or burning. (Holmes 2000)

In 1993 two mental health scientists examined self-harm not only as a symptom of other mental disorders, but also as its own separate disorder. They divided self-harm into the three basic types that were explained earlier and proposed that a syndrome of repetitive superficial self-harm should be regarded as a separate psychological disorder, classified under the subsection of “Impulse Disorders”. The outlined criteria for the disorder to be diagnosed are as follows: preoccupation with harming oneself physically, recurrent failure to resist urges to harm oneself and resulting in the destruction or alteration of body tissue, increasing sense of tension immediately before the act of self-harm, gratification or sense of relief when committing the act of self-harm, and the act of self-harm is not associated with suicidal intent and is not in response to a delusion, hallucination, or transsexual fixed idea, or mental retardation. (Holmes 2000)

Self-injury shares certain characteristics with addiction. The sufferer experiences the need to engage in the behavior in larger and larger quantities to achieve the desired effect. Said behavior shares some characteristics with addictive substances in that it provides relief from tension. This calming or numbing effect is the most common consequence of harming. People harm themselves because it makes them feel better. They turn to physical pain to deal with a deeper, more intolerable emotional pain that is linked to feelings of anger, sadness or abandonment. The injury is used to relieve the pressure that these emotions can cause. It can also jolt people out of states of numbness and emptiness. These mood changing effects and the increased tolerance seen in self-harmers have prompted research that suggests that cutting is much like alcoholism because the emotional pain is now being made physical. When the body is put into an adrenaline-like state, the brain releases natural opiates and other chemicals. Although not yet proven, it is suggested that when a person cuts, the body releases these chemicals and produces a state of euphoria that can become addictive. (Conterio 1998, Egan 1997, Spiratos 2003)

Several studies back the claim that self-inflicted pain can lead to feeling better. For example, scientists scanned the brains of people with a history of self-harm during a painful experimental task designed to mimic self-harm. They found that the pain led to decreased activity in the areas of the brain connected with negative emotion. This poses a confusing question. How could self-inflicted pain possibly lead to feeling better? New research now suggests that the key is the relief that occurs when something that causes intense pain is removed. (Franklin 2010)

Imagine that one morning you visit the doctor for a routine check-up, and later that afternoon the doctor’s office calls to tell you that you’re in the advanced stages of cancer and have weeks to live. Now imagine that the doctor’s office calls back five minutes later and tells you that they mixed up your lab work with someone else’s and you’re actually in good health. You would not immediately go back to how you felt before the first phone call, instead, you would feel extreme relief, lasting for hours or even days. It was not a reward that made you feel better, only the introduction and removal of something unpleasant.

Scientists conducted a study in which it was found that the removal of various forms of experimental pain were associated with a reduction in negative emotion in people with no history of self-injury. This relief was particularly strong for people who had higher levels of negative emotion. This second finding may help to explain why people with higher levels of negative emotion are more likely to engage in self-harm. They have more negative emotion to reduce, and therefore more relief to gain. These new findings are especially interesting because it turns out that both general negative emotion and pain-induced negative emotion are processed in the same brain areas. This means that pain relief and emotional relief are essentially the same thing. (Franklin 2010)

When people feel emotional pain, the same areas of the brain get activated as when people feel physical pain. In one study, these regions were activated when people experienced social rejection from peers. In another more real-life study, the same regions were activated when people who had recently broken up with their significant others viewed pictures of the former partner. This leads to the question of if physical and emotional pains have similar brain signals then why not take Tylenol for grief, loss, or despair? People who had experienced a recent social rejection were randomly assigned to take acetaminophen versus a placebo daily for three weeks. The people in the acetaminophen set reported fewer hurt feelings during that period. When their brains were scanned at the end of the treatment period, the acetaminophen takers had less activation in the brain areas where pain is processed. (Fogel 2012)

There are many myths and stereotypes about self-injurers. In an effort to dismiss these misunderstandings, it is important to be clear that first of all, not all self-injurers have Borderline Personality Disorder. Self-injury is just one of the possible indicators of Borderline Personality Disorder. Secondly, not all self-injurers have been sexually abused. The stereotype used to be if someone self-injured, they had been abused. This is not always the case, and many do not have any abuse history whatsoever. Third, self-injury is not a form of attention seeking. A “copycat” self-injurer may do it because they think it is “cool.” However, most do so because they do not know how to cope with their emotions. And finally, those who self-injure are not “crazy.” Based upon observations made by mental health professionals, they generally tend to be intelligent, creative, very sensitive and caring individuals who express difficulty communicating. These patients use their behaviors to be their voice as a way to cope. Many present themselves very well and other people are surprised to find they purposely hurt themselves. (Styer 2006)

Another myth about self-injurers has to do with the relationship between self-injury and suicide. It is important to be clear that self-injury is not a suicide attempt. Contrary to common popular belief, there is a difference between self-injury and suicide. It is difficult for the general public, and indeed many doctors, to understand why people would purposely hurt themselves to feel better. Logically, this does not make sense. If someone purposely cut themselves, then it is logically seen as a suicide attempt. But self-injury is not logical. Self-injury is an unhealthy way to stay alive and deal with whatever is occurring in one’s life. Suicide is a way to not cope at all. All a therapist needs to do is ask and patients will quite openly say if the marks on their body were self-injury or a suicide attempt. They know the difference. They just need to be asked. (Styer 2006)

Despite evidence that self-injury is reaching epidemic proportions, it is still considered a “rare” and “unusual” syndrome in the health care community just like anorexia and bulimia were twenty years ago. The goal now is to bring self-harm out of the closet and to take away the shame that surrounds the topic so that self-harmers can seek the help they need without fear. The mental health community must also be better educated in hopes that they can find ways to provide the best treatment for these patients. Self-harm is not some weird habit among modern teens, it is a growing occurrence that began more than sixty years ago. Self-harm is a powerful coping mechanism, and in order to help those who self-injure, therapists have to understand the role that it plays in their patient’s lives. Understanding the particular reasons for why someone self-harms is the key in helping that person to stop using self-harm as a way to cope. (Conterio 1998, Holmes 2000)

I self-harmed. For about 5 months I shut down and my only friend was the blade I used at night to cut my forearm and then my hips. Senior year is supposed to be the best year of your life. It is the final chapter of high school where you enjoy your life and reminisce on yesterday and how you’ve changed. This is the year that you leave your mark on this school and never look back. My senior year was anything but that. My world started to fall to pieces when I started my college applications. Looking back at my “achievements” I was angry with myself for the disgrace I had been. My expectations for myself had been much higher and I had not realized that I was far from meeting them. I began beating myself down. I became my own worst enemy. Heartbreak and rejection were no longer trivial. They fueled my own self-hate. I thought that I had gone crazy. I lost the capacity to deal with my own reality.

Things only got worse when I started hating on my body as well as my intellect. I could stand in front of a mirror forever and keep finding flaws. No matter how small, a flaw was a flaw and I would not let myself overlook such a failure. Perfection became my objective and the more obsessed with perfection I became, the more I realized I was far from it. I began to cry and realized that I hated myself. I hated my own being. I hated my own existence. I was a walking talking failure and I was a disgrace and disappointment to my parents. Or so I thought. I don’t know why I thought to do it, but before I could realize what I was thinking I was in the bathroom with shaking hands searching for my razor. I can’t really say if I was afraid at that point. I don’t think I was. I was so engulfed in hatred of myself that I began to fight with that razor to break it open. It was desperation so intense that I cannot describe. How do you explain an intense desire to cause yourself physical pain? I finally dismantled my weapon and all I could do was stare. Finally I grasped a thin silver blade in my hands and brought it to my skin. That was the beginning for me. The beginning of the intense and insatiable need to watch myself bleed. The constant voice in my mind telling me that I was not enough, that I was useless, that I was fat, ugly, stupid, psychotic. It was my own voice attacking me from the inside. I couldn’t defend myself from this entity inside me that despised me.

A friend reached out to a counselor because she was aware of what I was doing to myself. My parents were notified and I was placed in treatment. I was diagnosed with depression and was placed on antidepressants for a short amount of time. I am now much better than I was. Every once in a great while I may feel an urge but I have learned to control myself and look at the bigger picture. If I harm myself I also harm those that I love. Writing this paper and sifting through all this information was my closure. It was me facing something that had consumed me at one point. I would spend all day wanting to go home and cut. Remembering the way I felt is scary. Remembering the feeling of hopelessness and pain. Harming yourself is never the way to cope. You dig yourself into a ditch and the longer you stay the deeper it gets an

Works Cited

1. Egan, V. J. (1997). Self-Harm in Adults. British Journal of Psychiatry, 171(5), 389-393.
2. Turner, V. J. (2002). Self-Injury: It Hurts So Good. Journal of Clinical Psychology, 58(9), 1099-1107.
3. Lazar, S. (2013). The Controversy and Complexity of Self-Harm: A Comprehensive Review. Journal of Mental Health, 22(2), 110-121.
4. Conterio, K. (1998). Bodily Harm: The Breakthrough Healing Program for Self-Injurers. Hyperion.
5. Mayo Clinic. (2012). Self-injury/cutting. Retrieved from https://www.mayoclinic.org/diseases-conditions/self-injury/symptoms-causes/syc-20350950
6. Holmes, P. (2000). Understanding Self-Harm: A Guide for Parents and Professionals. Jessica Kingsley Publishers.
7. Holmes, P. (2000). Differentiating Self-Injury from Suicide Attempts: The Relationship between Destructive Behaviors and Family Functioning. Suicide and Life-Threatening Behavior, 30(3), 252-270.
8. Holmes, P. (2000). Self-Injury and Substance Abuse. Journal of Psychoactive Drugs, 32(4), 409-415.
9. Holmes, P. (2000). Self-Injury: Psychotherapy with People Who Engage in Self-Inflicted Violence. Taylor & Francis.
10. Holmes, P. (2000). Self-Injury and the Family. American Journal of Family Therapy, 28(2), 101-113.